Provider Demographics
NPI:1295976744
Name:PREMIER EYEWEAR
Entity type:Organization
Organization Name:PREMIER EYEWEAR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LICON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-855-4244
Mailing Address - Street 1:1830 GEORGE DIETER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4305
Mailing Address - Country:US
Mailing Address - Phone:915-855-4244
Mailing Address - Fax:
Practice Address - Street 1:1830 GEORGE DIETER DR STE 103
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4305
Practice Address - Country:US
Practice Address - Phone:915-855-4244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty